What Not to Have on Your Pharmacy Plan

Standard Exclusion in Pharmacy Benefits

What Drugs NOT to Have on your Pharmacy Benefits

Creating pharmacy benefits that take care of employers and employees is our passion. But how do we figure out what medications to exclude from the pharmacy plan and what to allow? This is where Standard Exclusions come into play.

What are standard exclusions for prescriptions?

These are prescription drugs not covered under an insurance plan’s medication benefits.

Why are certain medications not covered under insurance plans?

While expensive medications are often appropriate and necessary, many prescriptions have cost-effective alternatives that work just as well. By excluding certain high-dollar medications (including some specialty medications), insurance plans and their employees can save enrollees significant amounts of money without compromising their health.

Can my PBM help me determine my exclusion list?

Yes! Sona Benefits works with clients to determine exclusions specific to their population. It can be a highly effective tool to reduce your overall prescription drug costs while still providing the treatment members need.

Standard Exclusion Medication Examples:

  1. Fortamet (metformin ER): an expensive extended-release formulation of metformin that uses osmotic-release technology, but offers no clinical advantage over generically available metformin ER, which is a fraction of the cost.
    • Price of 30 day supply: Fortamet $2000 vs metformin ER $3
  1. Duexis (ibuprofen/famotidine): combines ibuprofen, an OTC pain reliever, with famotidine, an OTC acid reducer, which lowers the risk of developing stomach bleeds. These cheap generic medications can be taken separately to achieve the same clinical effect.
    • Price of 30 day supply: Duexis $2383 vs ibuprofen and famotidine $12
  1. Pennsaid (diclofenac topical solution): a topical solution pain reliever only available as a brand, but generic diclofenac gel contains the same active ingredient, offers comparable efficacy, and is much more cost-effective
    • Price of 30 day supply: Pennsaid $2388 vs diclofenac gel $24 
  1. Rayos (prednisone DR): a delayed-release formulation of prednisone, however, the delayed onset of action comes with a high price tag and does not confer any clinical advantage over generic, immediate-release prednisone
    • Price of 30 day supply: Rayos $2650 vs prednisone $3
  1. Gralise (gabapentin ER): extended-release gabapentin used for neuropathic pain and seizures. Generic immediate-release gabapentin taken several times daily can achieve the same clinical effect at a significantly cheaper price point.
    • Price of 30 day supply: Gralise $797 vs gabapentin $9


The most important thing is that members get the medications they need. As pharmacists, it is our job to determine when it makes sense to use a standard exclusion and when we need to do what is best for the patient. We work with prescribing physicians and the members to ensure that they are getting the treatment they need at a cost everyone involved can afford.


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